Predicaments of trees and turtles

A week of profound passages: Heather Ion convened sparkling minds exploring "the epidemic of health," KD's 90th, my 60th and Jesus rose again, too. Too much to think about, so I am mulling on the predicament of trees (in real forests) and turtles (crossing actual roads). The tree first.

Walking down the gravel road alongside Fighting Town Creek, we passed under a young oak bent a perfect arch. One of the pines killed by the bark beetles a couple years ago fell in the heavy spring storm, tangled with the oak, weighing it low, caught.


I thought all day about the improbable things that happen to real trees, so unlike the pictures we paint. In real forests (and neighborhoods) anything physically possible just might happen no matter what the predictions based on averages might expect. I was intrigued by the tangle off the ground that held the bent tree captive to the fallen on and even walked back later near dusk to find the predicament more improbable than I thought. The pine didn't just topple over, it snapped in the wind, caught its upper branches in the young strong oak, which bent but held the severed trunk a foot off the ground like a grey ghost might hold a troubled mind. The things that happen to trees ... and people.

Nathan Wolfe, a virologist Jonas Salk would have liked a lot, joined Heather's exploration of viral metaphor by phone. Nathan is named by Time Magazine this week as one of the 100 most influential people in the world (and on a much shorter list of influences on my daughter). Sparked by Heather Ion, he noted that virus are instructive for humans in how they "generate novelty" by combining and recombining genetic information constantly and promiscuously. Novelties (innovations) are tested against reality--also constantly--and those that work better stick long enough to generate more novelty. That's how viral life works, with some clues for us mammals.

I'll wait for a fuller posting on this until Heather has a chance to edit the transcripts. But you can see why it matters in the real neighborhood where you live.


Humans mash ideas together constantly, too, because we face not just threats but opportunities. As technology and knowlege move, it turns out that reality holds more possibilities for life than we had known. We are not contained by what has been possible yesterday, or even this morning. We can generate novelty, too. Indeed, the lives of all we love depend on the adaptive innovations that come from how our lives combine with others'.

Less than a month ago I was measuring my steps against geological phenomenon, noticing that I lived barely longer than one of Nathan's virus. Better generate novelty fast, for life is quickly passed on to others. The thoughtful community philanthropist behind our "epidemic" meeting passed on just last night. But Richard Cornuelle knew his ideas had combined with those of Jonas Salk (who passed on a handful of years ago himself). Lives are good when they leave a vital process more alive.

In the meantime, notice that turtles (and people) have predicaments that can be helped now and in very straightforward ways.


This is the patch of clutter where I moved a box turtle from his precarious rest two thirds of the way across a gravel road. Safe in his armored skin, he probably thought this an unnecessary novelty. But he didn't know about cars and I did, so I moved him unasked. He did not tarry to thank me and was long gone when I walked past again 45 minutes later. I thought of Loren Eisley's "star-thrower", walking the beach at dawn chucking stranded starfish back in the surf. Turtles are less poetic, but probably a lot more alive.

In Rock Hill to celebrate KD's 90th, I noticed an off-brand Baptist church announcing "Jesus stripped, shamed, tortured, killed...for you!!!" (Happy Easter). The ultimate Vital Novelty lost amid the violence. What wondrous life is this, asked the song, more helpfully astonished at the combination of divine and human. I wonder what it would look like if we believed it?

I thought of Bobby Baker, his Navigators and Liaisons intervening in the lives of hundreds of people (mostly moving slowly as turtles) every month getting them to where they need to be to have a better shot at health. Many of those lives are as unlikely as the tangled tree and many just as obviously exposed as the turtle in the road. Their hope is the novelty of competent compassion--hundreds of mundane but creative acts of vitality done quietly and a system that puts people in positions for life giving novelty.

- Posted on the journey

Ready... aim, aim, aim...

Boston is a city of revolutions past--and maybe future. Sometimes revolutions are simply things that just need to happen and are overdue. This is certainly the case with the "triple aim."

Among health wonks nothing is more obviously righteous as "the triple aim"-- lowering cost, improving quality and improving population health. Originally advanced by the Institute for Healthcare Improvement under Dr. Don Berwick, the triple aim is embedded at the very root of the current federal health care reform legislation. It also pops up at state levels such as Oregon (http://www.oregon.gov/OHA/action-plan/).


Just beyond the water over yonder is Bunker Hill; to the left behind the glass towers, Boston Commons. A more wonkish revolution is under way now, which is why a group from Memphis was here for a couple days. We were drinking deeply of the IHI / triple aim cup along with a hundred or more other folks from around the country. Representing both major hospitals in Memphis, the Med and The Church Health Center we listened to how these goals were being reached at large scale in upper Wisconsin and Oregon.

Of course the new triple aim is a footnote to the original one in Micah 6: "you know what the Lord requires already (some 2,600 years ago): do justice, love mercy and walk humbly." If we had done that, we would not need the new triple aim. The new triple aim is related to Micah a bit like the plumbing is related to Amos' prophecy that justice will role down like mighty river. Don't take plumbing lightly. Just because it depends on gravity, doesn't mean it is easy or obvious to get it to work. Same with health care.

We learned about CareOregon, a managed care organization for the poor that actually manages and actually cares. With tenacious decency, they use data like a righteous sword to carve waste and silliness from the lives of their members and providers. The result is dramatically more efficient services that are proactive, comprehensive, quick and responsive to what people really need. It passes for brilliance these days to notice that the most expensive patients needing the most medical services can be predicted by asking simple questions about substance use and family problems. And it passes for innovation when you do something non-medical about non-medical issues. Micah knew that would help, but did not need the cost savings to justify it.



Rebecca Ramsey, of CareOregon, shared how the basic revolutionary idea came from the SouthCentral Foundation in Alaska, which has built a large health services network on the highly participatory wisdom of the Native people. They (the people!) turn out to be pretty smart about the way people's health is connected to their families, community, decency and ... spirituality. The Native spirituality got left out of the story but the moral commitment to decency sure didn't. The key is that the embrace of those with the most complex conditions (almost often involving the snarly mix of substances, interpersonal violence and mental issues) is way cheaper than pretending the complexity isn't there. Mercy is cheaper; justice even more so.

These lessons are crucial for Memphis where we sit on a never-ending well of wicked disparities and poverty. We could be tempted to think we can't face the inherent complexity of multi-generational cascade of race and class. "We'll just do what we can; we can't afford world peace." Actually, IHI, Oregon and Wisconsin seem to say that world peace--taking it all on--is cheaper and more managing than trying to operate a hospital blind to the quiet violence of our patients' lives. We are way off the national curve for unneeded hospitalization that can be effectively managed only by getting involved in the complexity of those who have no real alternative. We are even further off the curve for expensive and futile care at the last months of life; that can be managed not by harshness, but by the gentle-kindness Micah aimed at. We're in a world war; why not work on world peace?

In the meantime, we can at least do a lot better. Micah thought he was only asking for what was obvious and doable: "you already know what God asks.....". IHI lives on the wonk-ish side, finding a buzz from the data and flowcharts. But they are talking about the same mercy, same justice and, ironically, the same humble seeking for what is possible on this earth.

- Posted on the journey

Adults behaving badly

In what appeared to be one its last actions before closing down in the fact of stampeding Vandals, the White House Office on Partnerships posted an article about "the Memphis Model" on its website. The Vandals thundered past to no affect, but may return at the walls next week, so you might go quickly to http://www.hhs.gov/fbci/resources/newsletter/040711.html#feature
to read the brief piece by Mara Vanderslice.

You've read the basics here before: hundreds of congregations connected to the big three faith-based treatment systems (Methodist LeBonheur Healthcare, Church Health Center and Christ Community Health Services) and pretty much anyone in town that wants to partner.

This would seem to be a fragile model for such wild oscillations in public policy. I could fill pages with simply lists of fundamental variables affecting the choices of all institutions involved. Given our 330 covenant congregations and these 3 key partners, there are at least 333 long lists of unknowns with big upsides and downsides that raise uncertainty to the 333rd power.

So we do the best we can on most days to consider the limits of what is possible to imagine and try to move that way with whoever we can do so that day. We try to respect each other and expect the best of all involved, and we are usually right. It is not pretty, but real.

However, we are not naive. We do not expect all the adults to behave well or to be able to keep to their best intentions, sometimes not even to keep their promises. In other words, it fits the times in DC and Memphis.

We muddle, which is what is possible for humans to do in complex and uncertain times. But we muddle while talking constantly to each other, making every incremental good choice we possibly can. It is not all that might be possible in the abstract, but all that are possible on this small and wild planet.

Sometimes the stars offer up an opportunity to move in big leaps. We are considering trying to become a model city for application of the Institute for Healthcare Improvement "triple aim." But that model seems to think that we could and should get all the powerful and smart people to agree, first, then act. The "memphis model" that appeals to the White House is more untidy and yet more ambitious. The heart of the Memphis model is to take advantage of every opportunity to bend the arc of justice in the right direction. It might work. And it might not. We continuously improve our aim and never give up.

In a week when we are told to be grateful our government employees are even going to be allowed to come to work, that seems pretty good.






- Posted on the journey

Shalomalization

Talking won't end disparities, but learning might. It depends on who is learning (and to a lesser extent, who is teaching).

Monday was April 4th, a sacred day in Memphis where Dr. King was murdered 43 years ago just down the street from the Center of Excellence on Faith and Health. In recent years we have joined with other organizations in town in a broad array of events, preaching, worship, lectures, march(es) and odds and ends. We shared a logo and a theme: "we are the beloved community."

Our patients and employees look like Memphis in terms of race so we aren't dumb about the subject. We are a very large organization serving hundreds of thousands of patients a year through the efforts of 10,000 Associates and a couple thousand affiliated physicians. Dr. King died before many of our staff were born yet the scandal lingers in the continued dramatic differences in the health of Black, White and Brown. Why? And what can we do?


So this year Methodist Healthcare decided to honor Dr. King by doing the labor of learning, seeking discernment about what our unfinished work is in removing disparities in the patients, families and neighborhoods we can influence.

We met in the Innovation Studio, seeing this as a most profound work of innovation. Led by Dr. Joyce Essien, Dr. Fred Smith and Dr. Elizabeth Williams we talked of the pain (and privilege) that are the lenses through which we are learning. We borrowed the IHP "4 frames" to keep our imagination from collapsing into simple "train everybody" reflex. Structure?How are we structured for disparities? And how could we lay down structures for equity? How might we use our symbolic role in Memphis? (The committee is called "equity" not "disparities," for starters.)(And we met on April 4th....). What does power have to do with it and us. How could we use our power? We will meet again, but the organization seems to be at a true learning moment, tuned to hear what is possible. And then do it.

That evening most of us went to the April 4th Foundation Gala, a very Memphis thing that always crackles with gritty power of history and hope. This year Dr. Jeremiah Wright keynoted and chose the power of cool analysis rather than the fire and thunder he is known for. He reminded us of the "dangerous King" who wanted the Movement to help put out the "house on fire." He channelled King's clarity about the three demons of America--race, militarism and materialism. The history we gathered to honor was still around us; and still ahead of us.

I was just a high school kid in the Baltimore burbs when King fell. And nobody in my family felt much sorrow as we lived in the soft racism of the unaffected. A few years later when the triple demons of America finally caught my attention, I dropped out of ROTC, sought simplicity and began to see race. I thought I would have to dump Jesus, too, since my old god seemed so complicit (he was!). Richard McBride, a Wake Forest chaplain, gave me books of Berigan and King, telling me that I needed to see the Church was bigger than my tame little god.

King blew a hole in my soul that let me out into the real world--the one God so loves; the one God has still not given up on. Everything else in my life has been a footnote to that.


Thursday night was a normal night in the hospital, which is to say that the place is electric with learning. In the Innovation Studio 85 people were learning the art of spiritual accompaniment--how to truly be present amid the illness of another. (Chaplain Jonathan Watkins had them shout "It's not about me!") (We should to that at executive meetings, I thought.) Down the hall in the Medical Arts Auditorium another ninety were learning the practical arts of caring for those living in dementia, led by Dr. Teresa Cutts and Chaplain Belisle, but illuminated by the experience of nearly everyone present. Another 40 people were attending via video-conference from our Germantown campus.

Although the 330 CHN congregations are hugely ecumenical and multi-hued, for the most part Thursday night feels like Black Church. It is. These are the ones whose brothers die too young and whose mothers will die much younger than mine. So the night closes in shared prayer filled with pathos and power.

This goes on week after week after week, pretty much all year round as the congregations open themselves to knowledge respectfully offered up in the hopes it is smart enough for their tough streets.

Nobody was just talking this week, not the equity committee, not Jeremiah and, for sure, Thursday night. Fred talks about education as the work of "shalomalization." That's what all this felt like to this white guy, grateful to be carried on the movement.

Can we learn the ways of shalom? Enough to do it, know it, let it fill and move us? Jesus cried at the question as he pondered his town. I'm a bit more optimistic. Yes, I am.


- Posted on the journey

Grand

My pedometer said it was 32,000 steps from the rim to the river where the base rock is 1.8 billion years old, give or take a hundred million. (It was less than 8 miles, but nearly a mile down, so I took little steps.) But every little shuffle was about 56,000 years of geology. So my first twitch down the trail passed democracy; the first lift of the knee marked all the time since Jesus, never mind Wesley, all the fruits of scientific method, the Indigo Girls and the Web.


I was silenced by the distant witness of petroglyphs that had improbably survived just a scramble up from the trail. But before my first foot touched the icy mud, I had passed them and all of recorded human history; and then all trace of humanity before the first switchback.


From then on, nothing but the raw creativity of time, wind, water and microbes. Entire oceans filled up, drained and up again. My favorite formation is the "great unconformity" where two geologic layers coincide impossibly because 1.25 billion years in between washed away without a trace. Think about it.


It is no small presumption to think we can comprehend the question posed by such a testament, much less an answer. But you would have to be dumb as a canyon full of rocks not to notice that life found a way. Infinitely serious creativity produces mule deer with ridiculous ears (they turn out to be really helpful in cooling), purple cactus (God only knows why) and trees that can grow in the most absurdly precarious places. God or time, some ask. God in time, I think.


And why we humans? Our sole capacity worth the evolutionary risk may be our capacity for awe, wonder, gratitude and sometimes, even kindness.

There is no litter in the canyon until you get back within a hundred feet of the rim and the 5 million people who come here. People at the bottom talk of "micro trash" and carefully scan their campsite before leaving. So I was so shocked when I neared the rim to see a plastic water bottle in the muddle trail that I stopped, carefully thought through how to get myself and my pack bent over far enough to reach it without spending the afternoon in that position. I figured it out, picked it up, poured out its purified water on a grateful pine, crushed the plastic into my pocket and walked on.

Only 1% ever go that far into the chasm, which might be about the same percentage of those attending church who ever give themselves to the vulnerability of the Spirit and its Question. Meanwhile, as Larry Pray suggests, walk softly.
Give way to those making their way up the path.
Thank the ones maintaining the trail.
Take on part of the load before giving advice.
Pay attention.
And pay with the currency of gratitude.


(And thanks to Karen and the kids for sending me, to Jeff for accompaniment and to John and John for trail guidance.)
- Posted on the journey

Audible Sigh

Bill Mallonee and Muriah Rose have played to a lot larger audiences than the one last night, but I'd be surprised if there have been any more tuned in to every whisper. They were the first artists to play in the Innovation Studio, consecrating the space with true, clear music that pealed back the cover of life. "Rural Route," looked -- and felt -- through the eyes of a friend who delivers mail in Indiana with lots of time for reflection. "Bakersfield" reached into the inner spaces of a man driven by the dust storms of the depression (a Tsunami of dust, Bill noted). "Friendly Fire" went into the free fire zone of a Vietnam Vet's return and then turned the lens slightly so that it reflected the spaces in between man and woman (Bill warned us). "Audible Sigh," of course (the last album of Bill's earlier band, Vigilantes of Love). This isn't "church music" any more than John the Baptist was just just a philosopher. Bill invites us to see through the dust and ghosts and spaces that look empty, but aren't. It can be scary, but we don't go alone.

The Innovation Studio is designed for just this labor of looking beyond, which is why we need all the art we can get. For one thing, you can actually hear yourself think. And we could hear Bill and Rose think, too, not something that happens much in the usual bar or church gig.


Earlier in the day a group of mostly retired physicians gathered here to honor Dr. Ralph Hamilton, who gave the first gift to build the whole Center of Excellence. They had each in their way pushed far beyond the obvious to find the possible healing in the lives of their patients. The previous day we spent an afternoon looking through the lens of those who take their own lives. Rick Kirchoff notes that "healing is a community venture." Indeed.


Art, science and spirit move toward what looks empty, believing that is where are most likely to find life raw, vital and new. None of the three -- art, science or spirit -- is tame or predictable because you just don't know what's out there until you open yourself to it. You don't "have" science, faith or talent. It has you and won't let go until just can't go another note. Bill has released 39 CD's so far, which he described as evidence of obsessive compulsion more than a career. Life won't let go.

In one of our more grandiose moments at Oakhurst Baptist, we once said that God only calls us to great things. Almost as soon as we heard it, we knew it was a trap. In real life, we never know if our day's labor is big or little until years later. It usually takes me about 5 years to figure out if I wasted my time on a project, a meeting, a conversation an audience. The IHP is 19, ARHAP 9, CHN 4 and the Center of Excellence just a few weeks old. But then sometimes it is clear right away, as last night.

Bill and Rose drove on to Independence, Missouri today, winding their way back to New Mexico. Do your heart, spirit and mind a favor and find out when they are coming near you. Better yet, reach out and bring them in.

- Posted on the journey

Grown ups and government

Last thursday a handful of us from Memphis met with about 20 leaders and staff of the government in the conference room of the Secretary of Health and Human Services. The Hubert Humphrey Building is one of the remarkably ugly in the whole city, except for the gorgeous quote from .... Hubert Humphrey right inside the front door: "the moral test of Government is how that Government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."

It takes a real grown up to do that kind of work and the folks here do the nitty grit labor involved 24/7/365 year after year after year. Not easy for DC these days is wall to wall weird and mean. This may be why a way of thinking about community health born in Memphis makes more sense than you might think. Nobody in Memphis is EVER surprised by the weird and mean. And we don't need or expect the course of human events to be pretty and clean. We just keep trying to focus on what we actually have to work with and then try to connect the moving parts as best we can.


That might sound a bit casual, but it is not. It does take the patient, tenacious grown-up labor of paying attention to what is possible and then trying to do it. And just what is possible? That is constantly coming in to view by working on what you already know is possible. The path is made by walking, not alone, but with a broad cast of others trying to act out of their best selves. It is not pretty on most days, but it is real.

Rev. Dr. Cynthia Davis is one of our exemplar pastors who spoke about what happens at the congregation level. It was so inspiring that it sounded almost magical. It isn't magic at all, of course. Enormous hours invested in building the strengths of spirit, mind and body called the Church so that when somebody needs some part of it, it can be the channel for God's love to flow toward healing, if healing is possible at all.

Bill Foege said that "tenacity doesn't always work. But it is the only thing that works."

We were meeting Thursday literally next door to the "situation room" where HHS people were tuned in like lasers to the fragile and horrific events taking place in Japan. Filled with all the apparatus you'd expect in a high-tech nerve center, the human beings were tuning to what was possible to do amid a situation that was impossible to expect. And they were doing it as best they could, (for which we should be grateful enough to pay our taxes without acting like spoiled four year olds all the time.).


On most days our work is dramatically undramatic. Jimmy Carter once called it "the mundane revolution." Doing what might help one thing after another 24/7/365 year after year.





- Posted on the journey